Regional musculoskeletal diseases of the low back. Cumulative trauma versus single incident

Discomfort in the low back is a common problem that has been investigated for centuries. The need to cope has not changed, but for the past 50 years, the way in which one copes has been dramatically changed by the interaction of a pathophysiologic insight within a legal construct. The development of the concept of "ruptured disc" as a cause of backache allowed, for the first time, the perception that a drastic dissolution of anatomy accompanied the discomfort. Regardless of the precipitant, the inference of "trauma" was compelling. This heuristic pathophysiologic inference found a ready ear in the Workers' Compensation Insurance system. If backache is a personal injury, it would be compensable if it arise out of and in the course of employment. Today one no longer suffers a backache; one "injures" one's back. The experience is further confounded if the sufferer perceives himself as an injured worker. He must prove his persisting illness in an adversarial climate that questions the validity of his symptoms and their pathogenesis on the job. In this contest, the worker, the clinician, and the ethical fabric of Workers' Compensation all fare poorly.